Night of Incredibly Bad OB Mojo

My night float started off with a 24 yr old G1 P0 at 36 + 2/7 wks with her baby in footling breech position, having contractions every 5 minutes, cervix dilated to 2 cm and 60% effaced.  We gave her IM terbutaline, but 90 minutes later she had made more cervical change, so high-risk OB came in to attempt an extraversion (to turn the baby around so s/he would be in head-down position).  Which failed.  Which led to an uneventful C-section that went very well.

After completing several ER admissions (including a 32-yr-old male in diabetic ketoacidosis who was not very compliant with his daily lantus regimen and whose last known HbA1c was a whopping 15.9%; and a tiny 82-yr-old woman with dementia, visual hallucinations, and a 4-night run of insomnia, who promptly fell asleep after 1 mg of haldol) I got a phone call from the village of Emmonak.

Things you never want to hear a health aide say:
1. This woman is having contractions every 3 minutes and she says she's 38 weeks pregnant, but I think she's only 30 weeks pregnant: The patient had no prenatal care for this pregnancy and we had no reliable records of her LMP or even of a positive urine pregnancy test.  I started to activate a medevac, thinking that the on-call pediatrician & I would have to fly out to Emmonak for the delivery.  I checked her old medical chart and found out she had no history of preterm delivery, just one baby delivered at 37 weeks in 2009.
2. I think her cervix is completely open and I think I can feel the baby's nose:  This is a very bad sign that the delivery is imminent and the presenting part is not the head.  There's no way the pediatrician & I can get to the village in time.
3. She started pushing, and I think a foot is coming out of her vagina:  OMG, it's another footling breech!  The health aide had me on speaker phone as I coached him through the breech delivery.
4. The baby is out but he's not breathing: The pediatrician took over the speaker phone and started coaching the health aide & his helpers through the process of neonatal resuscitation.
5. It's been almost 50 minutes and the placenta hasn't come out yet: By this time, the baby was doing better and the pediatrician was en route to Emmonak with the flight crew.  The health aide was trying to get pitocin started, as his helpers were applying gentle traction on the umbilical cord and massaging the fundus.
6. Do you think the medevac flight is bringing blood for transfusion?:  The health aide estimated a total blood loss of one liter and the mother was still bleeding.  The placenta finally came out, and I had the health aide insert his hand in the uterus and manually extract several blood clots and a possible fragment of placenta.  I could hear the mother screaming in the background on speaker phone.  The only medication for postpartum hemorrhage in the village clinic was methergine which I was hoping not to use.  The bleeding finally trickled to a halt, and I had them run IVF at full speed, given mother's tachycardia of 120 bpm.

Meanwhile, I was paged for an OB patient who presented with intractable vomiting, coffee ground emesis and one episode of emesis containing bright red blood, after she drank an entire bottle of R&R the day before.  She had been drinking through her entire first trimester, stopped for most of her second trimester, and was now at 26 weeks.  I wrote for IV zofran alternating with PR phenergan, then a loading dose of protonix 80 mg by IV, followed by a protonix drip at 8mg/hr to stop the GI bleed.  When she complained of epigastric pain, I ordered the magic "GI cocktail" (10cc each of maalox, viscous lidocaine, and benadryl) which soothed her and put her to sleep almost immediately.

Shortly before change of shift, I got a call from the village of Napaskiak: a G3P1 at 34 + 4/7 wks (with excellent dates by 10-wk ultrasound) was having contractions every 3 minutes.  After 2 doses of IM terbutaline and a liter of normal saline, the contractions had spaced out a little and were much shorter and less intense.  The health aide tried to check the cervix for dilation: "I put my entire hand up there as far as it could go and I still didn't feel anything, " which is a good sign.  I spoke with high-risk OB and we agreed to have the pt come to Bethel by boat (just a short 30 minute ride) for further evaluation.

Then I went home and fell, exhausted, into bed.